Exposure Therapy for Acute Stress Disorder

by John M. Grohol, Psy.D.
June 24, 2008

Before someone is diagnosed with post-traumatic stress disorder (PTSD), they are often diagnosed with a disorder called acute stress disorder. Why? Because PTSD is considered more of a longer-term, even chronic, disorder, while acute stress disorder occurs more immediately and generally doesnâ€™t last as long, especially if itâ€™s treated. Left untreated, acute stress disorder often turns into post-traumatic stress disorder.

So what kinds of treatments are most helpful with acute stress disorder (ASD)?

There are no medications approved for the treatment of ASD (although a medication may be prescribed for associated anxiety or depressive symptoms). So treatment usually is a type of psychotherapy.

Two types of psychotherapy often prescribed for ASD are either exposure therapy or trauma-focused cognitive restructuring. In the former, patients are taught and practice clinical relaxation and imagery techniques and, when mastered, gradually “exposed” to components related to the original trauma. This exposure is done either for real (in vivo) or via imagery techniques, depending upon the level of trauma and, in consultation with the patient, the therapistâ€™s experience and preference. Cognitive restructuring, on the other hand, doesnâ€™t expose people to the original trauma, but instead helps the person examine and deconstruct their negative, irrational thoughts surrounding the trauma. These thoughts often lead to negative emotions, such as anxiety, so the thinking goes that by dealing with them, one can deal with the anxiety and traumatic feelings.

Recent research has looked into which of these two techniques results in better outcomes for people. A randomized controlled clinical trial of people (non-military) who experienced trauma and who met the diagnostic criteria for ASD (N = 90) were seen at an outpatient clinic. Patients were randomly assigned to receive 5 weekly 90-minute sessions of either imaginal and in vivo exposure (n = 30), or cognitive restructuring (n = 30), or assessment at baseline and after 6 weeks (the wait-list control group; n = 30).

The researchers examined through clinical interviews and patient self-report measures to see whether they improved after treatment. They also assessed whether the person would meet the criteria for a PTSD diagnosis.

The results indicated that at the end of treatment, significantly fewer patients in the exposure group had PTSD than those in the cognitive restructuring or control groups. At a 6 month follow-up, patients who underwent exposure therapy were also more likely to not meet diagnostic criteria for PTSD and to achieve full remission of their acute stress disorder symptoms than the other two groups.

On assessments of PTSD, depression, and anxiety, exposure treatment resulted in markedly larger effect sizes at the end of treatment and the 6 month follow-up than cognitive restructuring.

The researchers concluded that exposure-based therapy leads to greater reduction in subsequent PTSD symptoms in patients with ASD when compared with cognitive restructuring. They said, “Exposure should be used in early intervention for people who are at high risk for developing PTSD.”

There arenâ€™t too many randomized controlled clinical trials of this nature for psychotherapy techniques, and fewer still that show such a clear differentiation between treatment options. Basically the researchers found that cognitive restructuring-focused therapy was little better than the control group. What the researchers found that works is exposure therapy, and thatâ€™s the treatment people should look for if they are diagnosed with an acute stress disorder.